Duty Report 4th November 2015

1. DUTY REPORT
EMERGENCY ROOM
4th NOVEMBER, 2015
GP on duty : dr. Dea & dr. Vira
Co-ass on duty : Dondy Juliansyah

2. PATIENT RECAPITULATION
 Mr. C  52 yrs old, CKD on HD
 Mr. NA  27 yrs old, Acute Gastroenteritis with Minimal
Dehydration
 Ny. R  45 yrs old, Chepalgia & HT Emergency
 Mrs. BA  88 yrs old, Low intake
 Mr. K  27 yrs old, chest pain
 Mr. H  46 yrs old, bronchial asthma

3. PATIENT’S IDENTITY
Name : N A
Sex : Male
Date of Birth : 21st October 1977
Age : 27 years old
Job : Soldier
Religion : Moslem
Marital Status : Married
Address : Jl. Pleburan No. 33 RT 12 RW 03 Rawamangun Jakarta

4. HISTORY TAKING
Auto and alloanamnesis on 4th November 2015 at 10
PM in the ER of RSPAD Gatot Soebroto.
Chief Complaint :
Patient complained of diarrhea 4 days before admission.

5. CURRENT ILLNESS
 4 days before admission, he complained of watery
diarrhea. The characteristic was with pulp but without
slime, blood, black stool or pain. The frequency was 5
times a day. Patient complained of abdominal pain, and
bloating. He had no complain of vomiting, nausea, nor
decreased of appetite. No complain in urination.
 3 days before admission, patient complained of fever.
Fever appeared especially in the afternoon and still
continuously. He never check the temperature while at
home. The fever sometime followed with chills but the
temperatur slightly decreased now.

6.  2 days before admission, patients went to a
clinic with the same complaint and received
treatment but no improvement, he forgot the
name of the medicine and did not take the
medicine anymore.
 Patient usually eats meal in a box from his
office or eat in the cafetaria. No history of
same complain in the office.

7. HISTORY OF PAST
ILLNESSES No history of the same complaint
 No history of high blood pressure, diabetic malignancy,
liver problem, kidney problems and lung problems
No family members have similar symptoms
DM (+) in his mother
No history of high blood pressure, malignancy, liver
problem, kidney problems and lung problems
HISTORY OF FAMILY ILLNESSES

8. HABITS AND LIFESTYLE
Smoking (-)
Alcohol (-)
Drugs and other medication (-)
Patient usually eats meal in a box from his office or eat in the
cafetaria

9. PHYSICAL EXAMINATION
VITAL SIGNS
General State: Mildly Sick
Consciousness : Fully alert
Blood Pressure : 120/80 mmHg
Heart Rate : 88 x/minute
Respiratory Rate : 18 x/minute
Temperature : 36,5 oC
Body Weight : 60 kg
Body Height : 165 cm
BMI : 22,05 (Normoweight)

10. PHYSICAL EXAMINATION
General Examination
Head : Normocephal
Eye : anemic conjunctiva (-/-), icteric sclera (-/-), sunken eyes (-/-)
Ears : normotia, discharge (-)
Nose : septum deviation (-), discharge (-)
Mouth : leukoplakia (-), thypoid tongue (-), hyperemis mucous(-), dry (-)
Neck : lymph nodes enlargement (-)
Thorax : symmetric, intercostal retraction (-)
Cor : regular 1st and 2nd heart sound, murmur (-), gallop (-)
Pulmo : vesicular breathing sounds, rales (-)
wheezing -/-
Abdomen : distended (-), bowel sound increased ,
shifting dullness (-), hepar & lien not palpable, absence of pain,
hypertympani
Extremities : CRT <2s, warm, pitting edema (-), clubbing (-), cyanosis (-), instan recoil
(+)

11. LABORATORY RESULTS
Examination Result Normal lab
Routine Blood Count:
Hb 13,9 12 - 16 g/dl
Ht 44 37 – 47 %
Erythrocyte 5.0 4.3 - 6.0 mil /ul
Leukocyte 11290 4800 - 10800/ul
Thrombocyte 244.000 150000 - 400000/ul
MCV 83 80 – 96 fL
MCH 28 27 - 32 pg
MCHC 33 32 – 36 g/dL

12. Examination Result Normal lab
Ureum 40 20-50 mg/dL
creatinin 0,7 0,5 – 1,5 mg/dL
RBS 122 < 140 mg/dL
Natrium 136 135-147 mmol/L
Kalium 4,0 3,5 – 4,0 mmol/L
Chloride 98 95 – 105 mmol/L

13. RESUME
 Patient was admitted to ER with watery diarrhea. The
characteristic was with pulp but without slime, blood,
black stool or pain. The frequency was 5 times a day.
Patient complained of abdominal pain, and bloating.
 Patient complained of fever. Fever appeared
especially in the afternoon and still continuously.
 On PE, patient's bowel sound increased and
hypertympani
 The Lab exam revealed leukocytes increased.

14. PROBLEMS LIST
 Acute Gastroenteritis with Minimal
Dehydration

15. Discussion
 Acute Gastroenteritis with minimal dehydration
Wattery diarrhea 5x/day
Leukositosis
• The characteristic was with pulp but without slime,
blood, black stool or pain.

16. Dehydration Score

17. Plan and Treatment
 Education plans :
 Keep the hygine of the food
 Therapy plans :
 No dehydration  oral fluid as much as the patient can drink
 Ciprofloxacin 2x400 mg (p.o)
 Paracetamol 3x500 mg (p.o) → if fever
 Attapulgit 2x600 mg (p.o)
 Diagnostic plans:
 Stool culture
 Monitoring plans:
 Blood Electrolit (Sodium, Potasium, Cloride)
 Urine output
 Random blood sugar

19. Prognosis
 Quo ad Vitam : ad bonam
 Quo ad Functionam : ad bonam
 Quo ad Sanationam : ad bonam

20. THANK YOU